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Objective: Measurement-based care (MBC), which collects session-by-session symptom data from patients and provides clinicians with feedback on treatment response, is a highly generalizable evidence-based practice with significant potential to improve the outcomes of mental health treatment in youth when implemented with fidelity; however, it is rarely used in community settings. This study tested whether an implementation strategy targeting organizational leadership and organizational implementation climate could improve MBC fidelity and clinical outcomes for youth in outpatient mental health clinics., Method: In a cluster randomized trial, 21 clinics were assigned to the Leadership and Organizational Change for Implementation strategy plus training and technical assistance in MBC (k = 11, n = 117) or training and technical assistance only (k = 10, n = 117). Primary outcomes of MBC fidelity (assessed via electronic metadata) and youth symptom improvement (assessed via caregiver-reported change on the Shortform Assessment for Children Total Problem Score) were collected for consecutively enrolled youths (ages 4-18 years) who initiated treatment in the 12 months following MBC training. Outcomes of each youth were assessed for 6 months following baseline., Results: A total of 234 youths were enrolled and included in intent-to-treat analyses. At baseline, there were no significant differences by condition in clinic, clinician, or youth characteristics. Youths in clinics using the Leadership and Organizational Change for Implementation strategy experienced significantly higher MBC fidelity compared with youths in control clinics (23.1% vs 3.4%, p = .014), and exhibited significantly greater reductions in symptoms from baseline to 6 months (d = 0.31, 95% CI: 0.04-0.58, p = .023)., Conclusion: Implementation strategies targeting organizational leadership and focused implementation climate can improve fidelity to evidence-based practices and clinical outcomes of youth mental health services., Plain Language Summary: Measurement-based care is an evidence-based intervention that has been shown to improve the outcomes of mental health services in dozens of randomized trials; however, it is not widely used in routine practice. In this randomized controlled trial of 21 outpatient mental health clinics and 234 youth, the authors found an organizational intervention which trained clinic leaders in skills to support the use of measurement-based care increased the extent to which patients received measurement-based care compared to control clinics where clinic leaders did not receive this training (23% vs. 3%). Youth receiving services in the clinics that received the organizational intervention also had greater reductions in mental health symptoms., Clinical Trial Registration Information: Working to Implement and Sustain Digital Outcome Measures (WISDOM); https://clinicaltrials.gov/; NCT04096274., (Copyright © 2023 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: Our objective was to develop an evaluation framework for electronic health record (EHR)-integrated innovations to support evaluation activities at each of four information technology (IT) life cycle phases: planning, development, implementation, and operation., Methods: The evaluation framework was developed based on a review of existing evaluation frameworks from health informatics and other domains (human factors engineering, software engineering, and social sciences); expert consensus; and real-world testing in multiple EHR-integrated innovation studies., Results: The resulting Evaluation in Life Cycle of IT (ELICIT) framework covers four IT life cycle phases and three measure levels (society, user, and IT). The ELICIT framework recommends 12 evaluation steps: (1) business case assessment; (2) stakeholder requirements gathering; (3) technical requirements gathering; (4) technical acceptability assessment; (5) user acceptability assessment; (6) social acceptability assessment; (7) social implementation assessment; (8) initial user satisfaction assessment; (9) technical implementation assessment; (10) technical portability assessment; (11) long-term user satisfaction assessment; and (12) social outcomes assessment., Discussion: Effective evaluation requires a shared understanding and collaboration across disciplines throughout the entire IT life cycle. In contrast with previous evaluation frameworks, the ELICIT framework focuses on all phases of the IT life cycle across the society, user, and IT levels. Institutions seeking to establish evaluation programs for EHR-integrated innovations could use our framework to create such shared understanding and justify the need to invest in evaluation., Conclusion: As health care undergoes a digital transformation, it will be critical for EHR-integrated innovations to be systematically evaluated. The ELICIT framework can facilitate these evaluations., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Timely identification of mental health needs and linkage to services is critical to provide comprehensive care for children with autism spectrum disorder (ASD). Pediatric primary care is well-positioned to facilitate this process through integrated care approaches. As a first step toward mental health integration, this study applied the Exploration, Preparation, Implementation, and Sustainment framework to characterize determinants of implementing integrated care practices for ASD., Methods: Sixty pediatric primary care providers and leaders from 3 organizations completed focus groups and surveys about identification of mental health needs in children with ASD and access to mental health services. Findings were integrated to examine convergence (ie, do the 2 methods confirm or find similar results) and expansion (ie, do the 2 methods provide insights beyond either method alone)., Results: Results converged regarding 3 primary influences to integrated care practices for ASD: 1) limited specialized mental health referral options for ASD, 2) unique structural characteristics of the mental health system act as barriers to accessing care, and 3) caregivers differ in the degree to which they understand co-occurring mental health conditions and pursue recommended services. Qualitative results provided expansion by highlighting unique implementation considerations (eg, alignment with health care delivery priorities and values) based on primary care characteristics., Conclusions: Findings confirm need for a tailored approach for linking children with ASD to appropriate mental health treatment. Results yield insight into the needs for organizational capacity to support integrated care and provide direction toward adapting an integrated mental health care model for children with ASD., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Latino adults are 66% more likely to have diabetes relative to non-Latino white adults. Prior research identifies depression as a significant risk factor for metabolic syndrome (MetS), but research examining this among Latinos is lacking. This study sought to examine the links between depression and MetS and clinically significant elevations in cardiovascular disease risk markers of MetS in a sample of community-dwelling older Latinos with type 2 diabetes., Methods: Participants were 332 community-dwelling older (≥60 years) Latinos with type 2 diabetes who completed the nine-item Patient Health Questionnaire and received a health checkup assessing body mass index (BMI), triglyceride and high-density lipoprotein (HDL) cholesterol levels, and blood pressure. Logistic regression analysis compared MetS rates of those meeting criteria for depression with those who did not. Secondary analyses examined the associations between depression and individual MetS components. All analyses controlled for demographic (e.g., income, age) and other potential MetS risk factors (e.g., smoking status, physical activity, alcohol level consumption)., Results: Depression was significantly associated with an increased risk of MetS (OR: 5.79; 95% CI: 1.32-25.42) and clinically significant elevations in triglycerides (OR: 2.71; 95% CI: 1.15-6.42) and reduced (HDL) cholesterol (OR: 2.46; 95% CI: 1.11-5.45). A significant association was not observed between depression and either BMI or hypertension., Conclusion: Depression is significantly linked to MetS, and most notably dyslipidemia, in older Latinos with diabetes. Causation, however, cannot be inferred from these analyses given the cross-sectional nature of the study. Future research should prospectively examine the directionality of this effect., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: Although there has been a dramatic increase in the number of evidence-based practices (EBPs) to improve child and adolescent mental health, the poor uptake of these EBPs has led to investigations of factors related to their successful dissemination and implementation. The purpose of this systematic review was to identify key findings from empirical studies examining the dissemination and implementation of EBPs for child and adolescent mental health., Method: Of 14,247 citations initially identified, 73 articles drawn from 44 studies met inclusion criteria. The articles were classified by implementation phase (exploration, preparation, implementation, and sustainment) and specific implementation factors examined. These factors were divided into outer (i.e., system level) and inner (i.e., organizational level) contexts., Results: Few studies used true experimental designs; most were observational. Of the many inner context factors that were examined in these studies (e.g., provider characteristics, organizational resources, leadership), fidelity monitoring and supervision had the strongest empirical evidence. Albeit the focus of fewer studies, implementation interventions focused on improving organizational climate and culture were associated with better intervention sustainment as well as child and adolescent outcomes. Outer contextual factors such as training and use of specific technologies to support intervention use were also important in facilitating the implementation process., Conclusions: The further development and testing of dissemination and implementation strategies is needed to more efficiently move EBPs into usual care., (Copyright © 2013 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Nutrition research, ranging from molecular to population levels and all points along this spectrum, is exploring new frontiers as new technologies and societal changes create new possibilities and demands. This paper defines a set of frontiers at the population level that are being created by the increased societal recognition of the importance of nutrition; its connection to urgent health, social, and environmental problems; and the need for effective and sustainable solutions at the population level. The frontiers are defined in terms of why, what, who, and how we study at the population level and the disciplinary foundations for that research. The paper provides illustrations of research along some of these frontiers, an overarching framework for population nutrition research, and access to some of the literature from outside of nutrition that can enhance the intellectual coherence, practical utility, and societal benefit of population nutrition research. The frontiers defined in this paper build on earlier forward-looking efforts by the American Society for Nutrition and extend these efforts in significant ways. The American Society for Nutrition and its members can play pivotal roles in advancing these frontiers by addressing a number of well-recognized challenges associated with transdisciplinary and engaged research.

Objective: Leadership is important in practice change, yet there are few studies addressing this issue in mental health and social services. This study examined the differential roles of transformational (i.e., charismatic) leadership and leader-member exchange (i.e., the relationship between a supervisor and their direct service providers) on team innovation climate (i.e., openness to new innovations) and provider attitudes toward adopting evidence-based practice (EBP) during a statewide evidence-based practice implementation (EBPI) of an intervention to reduce child neglect., Method: Participants were 140 case-managers in 30 teams providing home-based services to families in a statewide child-welfare system. Teams were assigned by region to EBPI or services as usual (SAU) conditions. Multiple group path analysis was used to examine associations of transformational leadership and leader-member exchange with innovation climate and attitudes toward adoption and use of EBP., Results: Transformational leadership predicted higher innovation climate during implementation, whereas leader-member exchange predicted higher innovation climate during SAU. Innovation climate was, in turn, associated with more positive attitudes toward EBP for the EBPI group., Conclusions: Strategies designed to enhance supervisor transformational leadership have the potential to facilitate implementation efforts by promoting a strong climate for EBPI and positive provider attitudes toward adoption and use of EBP., (Copyright © 2012 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: There is ongoing debate regarding the impact of youth behavior problems on placement change in child welfare compared to the impact of placement change on behavior problems. Existing studies provide support for both perspectives. The purpose of this study was to prospectively examine the relations of behavior problems and placement change in a nationally representative sample of youths in the National Survey of Child and Adolescent Well-Being., Method: The sample consisted of 500 youths in the child welfare system with out-of-home placements over the course of the National Survey of Child and Adolescent Well-Being study. We used a prospective cross-lag design and path analysis to examine reciprocal effects of behavior problems and placement change, testing an overall model and models examining effects of age and gender., Results: In the overall model, out of a total of eight path coefficients, behavior problems significantly predicted placement changes for three paths and placement change predicted behavior problems for one path. Internalizing and externalizing behavior problems at baseline predicted placement change between baseline and 18 months. Behavior problems at an older age and externalizing behavior at 18 months appear to confer an increased risk of placement change. Of note, among female subjects, placement changes later in the study predicted subsequent internalizing and externalizing behavior problems., Conclusions: In keeping with recommendations from a number of professional bodies, we suggest that initial and ongoing screening for internalizing and externalizing behavior problems be instituted as part of standard practice for youths entering or transitioning in the child welfare system.

Purpose: To determine whether adolescents who lose Medicaid entitlements when they leave foster care are subsequently able to secure employer-sponsored or student health insurance coverage., Methods: This was a 2-year follow-up study of a cohort of 404 adolescents leaving foster care in eight counties in a midwestern state. We conducted survival analysis to study predictors of time to first insurance loss, and logistic regression analysis to determine factors associated with insurance reacquisition, among these youth., Results: A total of 206 adolescents (51%) left foster care during follow up, of whom 138 (67%) lost health insurance coverage within a mean of 3 months of leaving foster care. Those who regained coverage (34; 17% of those leaving foster care) did so after a mean period of 8 months spent without insurance. Hazard of insurance loss was lower for employed adolescents (HR=.5; 95% CI=.4-.7; p < .0001), but only half of all adolescents leaving foster care reported being able to secure employment. Student health insurance did not reduce hazard of insurance loss. Boys had significantly lower odds of regaining insurance compared with girls (OR=.2, SE=.5, p=.003)., Conclusions: Most youth leaving the child welfare system seem unable to transition to other forms of health insurance coverage. Even those that do acquire coverage, do so after an inordinate period of time. Enacting existing extensions of Medicaid coverage until age 21 for foster care youth is necessary to provide the resources to address the considerable health and mental health needs among these youth.

Purpose: This longitudinal study examined the relationship between mental and physical health problems in a sample of high-risk youth served in the public sector., Methods: Participants included youth aged 9-18 years at baseline, randomly sampled from one of five public service sectors in San Diego County, California, and youths may have been active to more than one sector. Diagnoses for mood, anxiety, and disruptive disorders based on structured diagnostic interviews were determined at baseline and data regarding health-related problems were collected 2 years post-baseline., Results: Mood and disruptive behavior disorders were related to cumulative health problem incidence, as well as aggregate measures of health problems and severe health problems. In addition mood disorder diagnosis was associated with higher rates of infectious diseases, respiratory problems, and weight problems. Disruptive disorder diagnosis was related to higher rates of risk behavior-related health problems., Conclusions: The present work extends the research on the relationship between mental and physical health problems to adolescents served in the public sector, who are at especially high risk for behavioral and emotional problems. Potential mechanisms by which mental health problems may impact health problems are discussed. We suggest the development of effective interagency cooperation between medical and mental health systems to improve the care of youth with comorbid mental and physical disorders.

Social anxiety disorder in adolescents is increasingly recognized as a common condition that may precede onset of other mental health problems. However, few measures are currently available to screen for adolescent social anxiety, and little is known about their psychometric characteristics in school-based samples. To this end, the present study was undertaken as a psychometric cross validation of the Social Anxiety Scale for Adolescents (SAS-A). Exploratory and Confirmatory Factor Analyses (CFA) supported the original 3-factor structure of the SAS-A but retained fewer items than in the original scale. The revised scales demonstrated good internal consistency as well as criterion and concurrent validity. Despite including fewer items, psychometric characteristics of the revised scales were equivalent to or stronger than those reported in previous studies of the measure. As such, the present study provides initial support for the utility of the revised SAS-A as a measure of social anxiety in adolescent school samples.

Objective: To examine the prevalence of psychiatric disorders among youths from the following five public sectors of care: alcohol and drug services (AD), child welfare (CW), juvenile justice (JJ), mental health (MH), and public school services for youths with serious emotional disturbance (SED) in San Diego, California., Method: The Diagnostic Interview Schedule for Children was administered between October 1997 and January 1999 for 1,618 randomly selected youths aged 6-18 years who were active in at least one of the five sectors., Results: Fifty-four percent of the participants met criteria for at least one study disorder. Attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (50%) were much more common than anxiety (10%) or mood (7%) disorders. Youths who were active in the MH and SED sectors were more likely than those not in these sectors to meet criteria for a disorder; youths in the CW sector were least likely., Conclusions: Rates of psychiatric disorders, specifically ADHD and disruptive behavior disorders, are extremely high for youths in public sectors of care. Rates are generally higher in sectors designed to serve youths with psychiatric needs, but the prevalence of disorders was also high in sectors not specifically designed for this need (e.g., CW and JJ).

Objective: To examine the prevalence of substance use disorders (SUDs) among adolescents who received services in one or more of the following public sectors of care: alcohol and drug (AD), juvenile justice (JJ), mental health (MH), public school-based services for youths with serious emotional disturbance (SED), and child welfare (CW), in relation to age, gender, and service sector affiliation., Methods: Participants included 1,036 adolescents aged 13 to 18 years, randomly sampled from all youths who were active in at least one of the above five sectors of care (N = 12,662) in San Diego County California. SUDs were assessed through structured diagnostic interviews conducted from October 1997 through January 1999., Results: SUDs were found for youths in all sectors of care, with lifetime rates of 82.6% in AD, 62.1% in JJ, 40.8% in MH, 23.6% in SED, and 19.2% in CW. Rates of SUDs were significantly higher among older youths and males. Sector differences held even when accounting for the effects of age and gender., Conclusions: SUDs are highly prevalent among youths receiving care in the AD service sector as well as other sectors, particularly JJ and MH. These findings have implications for assessment, treatment, and service coordination for youths with SUDs in diverse sectors of public care.

Purpose: To examine the relationship of adolescent substance use and dependence to sexual risk-taking behavior in late adolescence and young adulthood., Methods: We prospectively examined self-reported sexual behaviors and substance involvement questionnaires in a sample of youth in substance abuse treatment programs and a comparison sample of sociodemographically similar community youths without histories of substance use disorders recruited from media ads. Assessments of sexual behaviors and substance involvement (78% white, 51% female) were collected at 2, 4, and 6 years after initial assessments, as they transitioned from middle adolescence to young adulthood (from age 15.5 to age 21.5 years, on average). The two samples were compared using Chi-square, analysis of variance, and multivariate analysis of variance approaches. Continuous indicators of high-risk sexual behaviors and substance involvement were analyzed with multiple regression., Results: Earlier age of onset to sexual activity, more sexual partners, less consistent use of condoms, more sexually transmitted diseases (STDs), and greater prevalence of human immunodeficiency virus testing were reported by youth in the clinical treatment sample relative to sociodemographically comparable nonabusing community youth. High rates of STDs were found among females, and more substance-abusing females reported pregnancies than community females. Substance involvement continued to be associated with high-risk sexual behavior throughout the transition into young adulthood., Conclusions: Youth identified with substance problems are more likely to engage in risky sexual behaviors during adolescence and to continue risky sexual behaviors to the extent that substance problems persist. Risk reduction education should be included with adolescent substance abuse treatment.

Purpose: To examine the relationship of adolescent alcohol and drug use over a 5-year period to cumulative health problems in late adolescence and young adulthood., Methods: We prospectively examined self-reported health problems in a sample of adolescents, some of whom received treatment for substance use disorders and had consistently poor substance use outcomes (n = 38), some of whom received treatment for substance use disorders and had positive substance use outcomes (n = 30), and a low alcohol and drug use community comparison group (n = 48). Data regarding health-related problems of these adolescents (mean, 15.9 years; 83% Caucasian; 56.5% female) were collected at 2, 4, and 6 years following initial assessments., Results: Alcohol and/or drug involvement severe enough to warrant treatment during adolescence was associated with more cumulative health problems and severe health problems for girls and more cumulative health problems for boys. Protracted and continuous abuse of alcohol and drugs was associated with more cumulative and severe health problems for girls and more severe health problems for boys., Conclusions: These results suggest that significant health problems and concerns are related to both brief and protracted alcohol and drug abuse during adolescence. Health problems will likely become even more evident as early-onset, chronic substance abusers continue to age.

Objective: In adolescents, conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), and depression are frequently comorbid with substance dependence (SD). We hypothesized that the prevalence and severity of CD, major depressive disorder (MDD), and ADHD would differ by gender, and that these conditions would associate differentially with severity of SD in males and females., Methods: We examined these issues, using standardized diagnostic interviews, in 285 male and 82 female adolescents referred for comorbid CD and SD., Results: Males and females did not differ significantly in severity of substance involvement, MDD, or ADHD, but males had more severe CD. MDD severity was the only variable significantly associated with SD severity for females, while for males, severity of CD combined with MDD and ADHD was significantly associated with SD severity., Conclusions: Among referred adolescents, CD, MDD, and ADHD may all be important concomitants of SD in males, while in females, depression may be the primary variable related to SD.